Volumetric modeling: from theory to practice

Alexander Borodko, surgeon at the Visit Cosmetic clinic, full member of the Russian and Ukrainian associations of plastic reconstructive and aesthetic surgery (Ukraine, Kyiv)

Anatomy and physiology of facial aging

The aging process of the face involves, in addition to thinning and dehydration of the skin, also a decrease in the tone of facial muscles, inelasticity of ligaments, a decrease in the thickness of subcutaneous fatty tissue, osteoporosis, accompanied by changes in the thickness and ratio of the bones of the facial skull.

The vertical position of the head, given by nature to humans, and gravity lead to a gradual “sliding” of the soft tissues of the face downwards. Moreover, this movement occurs with a delay at three points of fixation, which are located on the same vertical line, conditionally passing through the outer corner of the eye on both sides of the face. The fixation point means a small area that includes the skin, subcutaneous fat, muscles and fascia, as if “pinned” through all these layers to the periosteum. The tissues in these areas practically do not move downward in relation to the bone.

The first fixation point is located on the upper-outer edge of the orbit and prevents the final “sliding” of the eyebrow onto the upper eyelid, holding its outer tail part.

The second fixation point, located under the most protruding area of the zygomatic bone, does not allow the soft tissues of the zygomatic and infraorbital areas to completely “slide” onto the upper lip.

And finally, the third point forms the so-called “bulldog cheeks” and “bitter folds,” thereby preventing the soft tissue of the buccal and mandibular zones from shifting to the lower lip and chin.

As a result of gravitational ptosis, over the years we observe such phenomena on the face as low eyebrows, which is often accompanied by an excessive fold of the upper eyelid, often moving to the area of crow's feet (external periorbital wrinkles). If in youth there was slight swelling of the lower eyelids and a tendency to puffiness of the face, then with age, due to the above and many other reasons, these features can manifest themselves as specific “bags” - hernial protrusions of the lower eyelids under the eyes, a pronounced nasolacrimal groove, often passing under the overhang of the soft tissues of the zygomatic zone (zygomatic “bag”).

The deepening of the nasolabial fold is often accompanied by a displacement of the skin “ridge” from the infraorbital zone onto it, which, in turn, can cause a “failure” under the nasolacrimal groove or lower eyelid. Labial-mental folds, or “folds of bitterness,” can be a continuation of the nasolabial folds, but are more often visible separately and, as a rule, are accompanied by a thinning of the red border of the upper lip, especially in the outer parts, and a “turning down” of the corners of the mouth.

The logical conclusion of gravitational ptosis of soft tissues in the lower parts of the face is the smooth transition of “bitter folds” into “bulldog cheeks” and the absence of expression of the cervical-mental angle due to weakening and divergence along the midline of the superficial muscle of the neck (platysma).

Evolution of problem solving

Until the mid-90s of the last century, plastic surgeons around the world were unanimous in solving the above problems with braces, and only braces. The results of the operations could vary in their effectiveness and duration of effect, depending on the experience, knowledge, talent of the surgeon and the adequacy of the patient. Everything would be fine, but only after the “rejuvenation” the person was no longer the same. Well, he’s not at all like his younger self. The problem of tightening the nasolabial folds was difficult to solve.

The volumetric modeling technique is based on the technique of autologous fat grafting (not to be confused with lipofilling), first described by the American surgeon Dr. Coleman

The American surgeon Dr. Little, almost simultaneously with the French surgeon Daniel Marchak, proposed a deep supraperiosteal face lift, which, along with a lift, partially solved the problem of returning volumes in the cheek-zygomatic areas. But the risk of damage to the motor branches of the facial nerves in the absence of sufficient experience and the degree of need for such an operation turned out to be incomparable. Endoscopic deep lifting of the upper and middle areas of the face, proposed by the American surgeon Dr. Biggs, helped solve the problem through visual control with an endoscope. So the problem of reliable recording of the achieved results has still remained completely insoluble.

In the same 90s, along with plastic surgery, a branch such as aesthetic medicine began to develop, which took an intermediate place between surgery and dermatocosmetology. In Europe and the States, Botox and injectable collagen (Zyderm, Zyplast) have suddenly become fashionable. After the epidemic of bovine spongiform encephalopathy, which broke out in England and reached its maximum in 1992-93, collagen, which was made from animal skin, was replaced by hyaluronic acid - in the form of the preparations Restylane, Perlane (Sweden) and Hyalaform "(USA). The European drug Dysport has become a competitor to the American Botox. Dermatologists have the opportunity to more visible facial rejuvenation using non-surgical methods, which, naturally, caused displeasure among plastic surgeons and divided them into two almost warring camps. However, time is the best healer. Today, both are trying to jointly address the growing demand for “rejuvenation.”

Volumetric modeling

Every day something new appears. Today, volumetric facial modeling with fillers is on the crest of a wave. Simply filling out wrinkles and nasolabial folds has somehow become a thing of the past. The new, as we know, is the well-forgotten old. Whatever one may say, the volumetric modeling technique is based on the technique of autotransplantation of fat (not to be confused with lipofilling), first described by the American surgeon Dr. Coleman.

Understanding age-related physiological changes can help avoid invisible “underwater reefs” that are not visible if the doctor focuses only on external anatomical signs

According to this technique, transplantation is performed under anesthesia with thin, blunt cannulas that do not injure the vessels, in an operating room. Local anesthesia of the donor and recipient areas is not performed. Particular emphasis is placed on sufficiently deep placement of the injected fat, and in the periorbital region - on the periosteum. In this case, it is permissible to transplant from several to tens of milliliters of fat.

Today it is very important to understand that fat is not hyaluronic acid, and the body’s reaction to both is completely different. Moreover, the reaction to biphasic and monophasic hyluuronic acid is different. If the first practically does not cause the formation of connective tissue, then the second very much can. But trouble can be caused with two-phase acid. For example: are matches a bad thing? No. It all depends on whose hands they are in. This simple rule applies to all items, and the products offered to you and me too.

The level and amount of the drug administered in one session in the same area is very important. Not the least, and perhaps even the main role is played by the doctor’s unhurried and correct assessment of the condition of the soft tissues of the patient’s face, not to mention the adequacy of his desires. In this regard, it is useful to remember the saying of the ancients: est modus in rebus (Latin) - there is a measure in things.

For a primary superficial assessment of the face, it is sufficient to understand the mechanisms and signs of aging described above. To learn how to place a drug at the right level in the right place, in addition to knowledge of injection techniques and basic schemes, anatomy and physiology, almost daily practice is required for more than one year. Following this, intuition will appear. You can't go far with talent alone.

Taking into account physiological changes

In educational literature, in reports at congresses and master classes, much attention is paid to knowledge of facial anatomy and the issue of physiology is rarely considered.

Meanwhile, understanding age-related physiological changes can help avoid invisible “underwater reefs” that are not visible if the doctor focuses only on external anatomical signs.

The genetic program of aging, laid down by the Creator in our bodies, involves a gradual decrease in the intensity of metabolic processes with age. This is at the biochemical level. At the morphological level in relation to the face, and not only the face, this is expressed in a significant decrease in the number of vessels per unit area, the number of sweat and sebaceous glands, the rate of restoration and healing of the skin when damaged, a decrease in the degree of innervation by sensory, motor and autonomic fibers, etc. .d.

Since we are talking about the use of fillers, it is very important to take into account the above vascular changes, and here’s why. As a rule, even with a reduced number of arteries, blood flow to the soft tissues of the face does not suffer so much. Another thing is veins and lymphatic vessels. We often observe an expanded capillary network on the face in older people (I’m not talking about pathological skin conditions). In the absence of pathology, this always indicates that arterial blood has entered the soft tissues, an exchange of oxygen and oxidation products has occurred, and now these products should safely leave through the venous and lymphatic pathways, but this does not work. It doesn’t work because higher blood pressure brought more blood to its destination than the impoverished network of venous and lymphatic vessels can carry. At the same time, the “transshipment base” cannot cope with the load, and hitherto invisible capillaries on the skin open (you have to place what has arrived somewhere).

The denser the filler and the more superficially it is introduced, the higher the likelihood that after a couple of weeks you will get a long-term seal that does not disappear for years at the injection sites.

Now let's imagine a situation where, in the above condition, the doctor injects decent volumes of hyaluronic acid in one session.

The injected hyaluronic acid filler, regardless of whether it is biphasic or monophasic, with its large volume puts pressure on all vessels, especially venous and lymphatic drainage in the injection area is affected. Then the formation of a vicious circle begins, which is no longer possible to break.

In the 90s, at the peak of the fashionable fight against so-called cellulite, histological studies established that this is not a disease at all, but the usual germination of subcutaneous fatty tissue with connective tissue cords from the deep layers of the dermis to the muscular fascia, which causes the appearance of the abdomen and thighs on the skin retractions (“orange peel”). The reason for this germination, as a rule, is hormonal and hereditary in nature and lies in a significant decrease in the number of vessels in the subcutaneous fatty tissue per unit area (mainly venous and lymphatic), and, as a result, there is a disruption in the outflow of interstitial fluid with under-oxidized waste products of fat cells .

This, in turn, causes the formation of a significant amount of fibrous tissue, which is the same connective tissue strands. As a result, “packages” of fat cells are “packed” into a fibrous membrane, which further complicates the flow of blood, and even more so the outflow of venous blood, lymph and interstitial fluid. Thus, the vicious circle closes and gets worse. This illustrative example of cellulite explains the processes that occur in the soft tissues of the face, too, but more due to age and to a lesser extent. And if all the above processes are ignored when analyzing the patient’s face, then this expression can, without wanting to, be strengthened.

Perhaps it will come as no surprise to anyone that the denser the filler and the more superficially it is introduced, the higher the likelihood of getting a long-term, lasting seal in the injection sites of the drug after a couple of weeks. Often this complication occurs from excessive zeal when filling the nasolabial or labiomental folds. It does not matter whether the hyaluronic acid is biphasic or monophasic. The reason for this complication is that the dermis itself is a fairly dense formation compared to the underlying subcutaneous fat and muscles. Like any other organ, the skin needs normal blood supply, utilization of useful components brought by arterial blood and “taking out the garbage from the house” through the venous and lymphatic pathways. In addition, there is also a gas exchange and sweating function. The hyaluronic acid preparation introduced intradermally pushes apart and “presses” the surrounding structures, squeezing the vessels, nerves, sweat, sebaceous glands and respiratory pores closest to it.

But the body is a self-restoring system, and if concomitant pathologies, any congenital anomalies, constitution or age are not a serious obstacle, then a rapid adaptation to the “uninvited guest” occurs due to the inclusion of “dormant” vessels and capillaries in the work, as well as due to sprouting (compensatory reinnervation). In a situation where compensatory abilities do not work (this applies not only to existing features or pathology, but also to excessive amounts of the drug), ischemia and scar formation occurs, as in a stroke or heart attack. It's simple. Therefore, excessively pale, cyanotic skin and a pasty face should alert the doctor.

Cannulas or needle?

The technique of administering hyaluronic acid preparations with cannulas, which is now so popular among dermatologists, has shown itself to be both positive and negative. The desire of doctors to reduce vascular injury from sharp needles is positive. The sad thing is that the drug is often located in the subcutaneous fat and reveals itself either as ridges, cords and tubercles that are palpable to the touch or visible to the naked eye. What can we say about conditionally neutral synthesized hyaluronic acid, even if the patient’s own fat, injected purely into the subcutaneous fat layer, very often gives the same results.

The feeling of contact with the periosteum is much easier to develop by direct perpendicular insertion of the needle through all soft tissue layers until it comes into contact with the bone and the use of rapidly degrading drugs - for example, hyaluronic acid of the lowest concentration and density for mesotherapy, which at first can serve as a volumetric filler, especially in the periorbital area

The bottom line is that fatty tissue is the least blood-supplied and innervated layer, unlike the dermis and facial muscles. Consequently, all the conditions are present for neither one nor the other to really “take root” and fibrosis to form.

Plastic surgeons have long ago learned this as an axiom and try to perform injection fat transplantation as deeply as possible. The ideal option is placement on the periosteum, and in places where it is absent - subfascially or in the intermuscular space.

For example, replenishing the volume of a “sunken” upper eyelid is actually done with a thin, sometimes slightly curved cannula. Fat or the same hyaluronic acid should be placed between the orbicularis oculi muscle and the muscle that lifts the upper eyelid, located a little deeper. There is a small space between them. Question: how to determine it? Answer: through your own trial and error, preferably under someone’s guidance, since distances indicated in numbers and diagrams do not work here. The main role is played by the doctor’s personal feeling of the depth of the soft tissues, contact with the periosteum (in cases where the drug is placed on the bone), the feeling of resistance of the syringe piston when injecting fat or drug, and much more, which can only be gained through experience. From the above, the conclusion suggests itself that a novice doctor should not even touch volumetric modeling. Not at all.

The feeling of contact with the periosteum is much easier to develop by direct perpendicular insertion of the needle through all soft tissue layers until it comes into contact with the bone and the use of rapidly degrading drugs - for example, hyaluronic acid of the lowest concentration and density for mesotherapy, which at first can serve as a volumetric filler, especially in the periorbital area. The same drugs can be used to train the sensation of the dermal layer when simply filling in wrinkles. Overcorrection, vessel injury and hematoma may occur, but this can be corrected by simply pressing the injection site for three minutes (what's the rush?) and subsequent use of heparin-containing ointments and physiotherapy aimed at eliminating overcorrection.

We know from experience: patients will forgive. But... if without proper practical training, and a “long-lasting” drug, and in considerable quantities, and immediately with a cannula, and even in the wrong layer, there may be financial, physical and moral troubles, which will result in subsequent persistent uncertainty about to yourself.

Therefore, for successful volumetric modeling it is important:

• learn to choose the correct depth of administration and the appropriate drug;
• never try to achieve full volumetric correction at one time (for the reasons described above);
• remember that a cannula does not guarantee success;
• listen carefully and patiently to the patient’s wishes, suggestions and “brilliant” ideas - and, dividing by 10, do everything so as not to harm him.

First published: KOSMETIK international journal, No. 1 (47) / 2012, pp. 24-30